CMS Emergency Procedures & Response 3 — Questions and Answers
Question 1: A CMS specialist is advising a dual-eligible beneficiary (Medicare and Medicaid) who needs emergency mental health services. Which program is the primary payer?
- Medicaid always pays first for mental health services
- Medicare is the primary payer and Medicaid pays secondary costs Medicare does not cover (Correct answer)
- The beneficiary must choose one program per service
- A Special Needs Plan is required to coordinate benefits
Correct answer: Medicare is the primary payer and Medicaid pays secondary costs Medicare does not cover
For dual-eligible beneficiaries, Medicare always pays first as the primary payer, and Medicaid covers remaining costs up to its limits.
Question 2: During a public health emergency declared by HHS, CMS may issue 1135 waivers. What is the primary purpose of these waivers?
- To permanently eliminate Medicare cost-sharing requirements
- To temporarily waive or modify certain Medicare and Medicaid requirements to maintain access to care (Correct answer)
- To allow non-licensed providers to bill Medicare permanently
- To replace Medicare with Medicaid during the emergency period
Correct answer: To temporarily waive or modify certain Medicare and Medicaid requirements to maintain access to care
Section 1135 waivers temporarily waive or modify certain federal healthcare requirements so providers can continue serving beneficiaries during emergencies.
Question 3: A Medicare beneficiary enrolled in a PACE program has a medical emergency. Who is responsible for coordinating their emergency care?
- The beneficiary's primary care physician
- The PACE interdisciplinary team, which retains responsibility for all care coordination (Correct answer)
- The local hospital emergency department
- CMS regional office staff
Correct answer: The PACE interdisciplinary team, which retains responsibility for all care coordination
PACE organizations retain full responsibility for all care coordination, including emergency services, as part of their capitated care model.
Question 4: When a Medicare beneficiary in a skilled nursing facility (SNF) develops a sudden severe condition, under what circumstance would Part A NOT cover their emergency hospital transfer?
- If the beneficiary has not yet met their Part A deductible
- If the beneficiary has exhausted their SNF benefit days and their 60-day benefit period has not reset (Correct answer)
- If the beneficiary is enrolled in a Medicare Supplement Plan N
- If the emergency occurs on a weekend
Correct answer: If the beneficiary has exhausted their SNF benefit days and their 60-day benefit period has not reset
If a beneficiary has exhausted their 100 SNF benefit days and has not re-qualified through a new qualifying hospital stay, Part A will not cover additional inpatient care.
Question 5: A Medicare beneficiary calls after receiving an Advance Beneficiary Notice (ABN) before a procedure. The beneficiary signed the ABN but now argues the procedure was actually an emergency. What is the ABN's significance in this case?
- The signed ABN waives all Medicare appeal rights
- An ABN cannot be issued for emergency services; if issued, it is invalid and Medicare must pay (Correct answer)
- The ABN shifts financial liability to the beneficiary regardless of emergency status
- The ABN requires the beneficiary to pay upfront but they can recover costs later
Correct answer: An ABN cannot be issued for emergency services; if issued, it is invalid and Medicare must pay
ABNs are not valid for emergency or urgently needed services; issuing one for a true emergency does not shift financial liability to the beneficiary.
Question 6: During an emergency, a hospital is operating under a CMS 1135 waiver. A provider at the hospital is licensed in a neighboring state but not the state where the emergency occurred. Under the waiver, can they be reimbursed by Medicare?
- No, Medicare always requires licensure in the state of service
- Yes, 1135 waivers can allow Medicare reimbursement for providers licensed in another state (Correct answer)
- Only if the provider is enrolled in Medicaid in the state of service
- Only for services provided in federally qualified health centers
Correct answer: Yes, 1135 waivers can allow Medicare reimbursement for providers licensed in another state
Section 1135 waivers can waive state licensure requirements, allowing providers licensed in other states to be reimbursed by Medicare during declared emergencies.
Question 7: A Medicare beneficiary with end-stage renal disease (ESRD) misses their dialysis appointment due to a severe snowstorm. What should the CMS specialist advise regarding emergency dialysis access?
- The beneficiary must wait until their regular facility reopens to avoid cost-sharing penalties
- The beneficiary can seek dialysis at any Medicare-certified facility and Medicare Part B will cover it (Correct answer)
- The beneficiary must contact CMS directly for emergency dialysis authorization
- Emergency dialysis is only covered under Part A if the beneficiary is hospitalized first
Correct answer: The beneficiary can seek dialysis at any Medicare-certified facility and Medicare Part B will cover it
Medicare Part B covers dialysis at any Medicare-certified facility, giving ESRD patients flexibility to seek treatment at alternate sites during emergencies.
CMS Emergency Procedures & Response 3
A CMS specialist is advising a dual-eligible beneficiary (Medicare and Medicaid) who needs emergency mental health services.
Which program is the primary payer?